Tutoring 5/3/17 Melanie Jaeger mjaeger3@uthsc.edu Nutrition support Tutoring 5/3/17 Melanie Jaeger mjaeger3@uthsc.edu

Metabolic Concepts

Patient DM (5’11” 150 lbs) is getting the following TPN regimen: D300, C60, IL50. How many kcal/kg/day is he receiving? D=dextrose C=Clinisol (amino acids) IL=Intralipid (fat) 1760 kcal total 25.8 kcal/kg/day

What is the ASPEN recommendation for BG control for most patients? 80-100 <180 <140 140-180 D

What is the most accurate method of nutritional assessment? Bioelectrical impedance analysis BMI CT Skinfold measurements C.

Which of the following surrogate markers is the best representation of acute nutritional status? Albumin Pre-albumin Transferrin Serum protein B

Match the following conditions with their nutritional assessment categories. Burn Anorexia nervosa COPD Starvation-related malnutrition Chronic-disease related malnutrition Acute disease related malnutrition A-3 B-1 C-2

Patient PH’s nitrogen balance is +7 Patient PH’s nitrogen balance is +7. Which of the following statements is true about PH? PH is in nitrogen equilibrium. PH is in an anabolic state. PH is in a catabolic state. PH is losing muscle mass. B

Nutritional requirements

Generally, how many kcal/kg/day should be provided to a patient in which weight maintenance would be appropriate? 35 kcal/kg/day 20 kcal/kg/day 25 kcal/kg/day 30 kcal/kg/day C

MK is a 24 yo, 80 kg M s/p MVC with TBI MK is a 24 yo, 80 kg M s/p MVC with TBI. Which of the following would be an appropriate amount of protein for him to receive per day? 65 g 100 g 120 g 180 g D

Parenteral Nutrition

Note: if the gut works, use it!

Which of the following statements is true? The osmolality limit of PN administered peripherally is 1200 mOsm/kg. Volume-restricted patients should get PN through a central line. A 0.22 micron filter is used for TPNs containing lipids. Clinimix is appropriate for patients who will be on PN for an extended period of time. B

Which of these CAN be added to TPN? Calcium chloride Iron dextran Sodium phosphate Sodium bicarbonate C

Around what TG level should lipids and propofol be stopped? 100 200 300 400 500 D

Which trace element(s) should be held in patients with liver failure? Zinc Copper Chromium Manganese Selenium B&D

You are on the nutrition support team for KD You are on the nutrition support team for KD. Her ABG’s lead you to believe KD is in metabolic acidosis. Her K is 3.1. What form of potassium should be added to her TPN? Potassium chloride Potassium acetate Potassium cannot be added to TPN. Bolus KD with 40 mEq KCl. KD’s K level is normal. Do not give any additional K. B

Enteral nutrition

Match the disease state with the appropriate EN formulation. Chemically-defined, nutritionally-complete (Vivonex RTF) Polymeric, nutritionally-complete, concentrated (Nutren 2) Concentrated, low protein, low or no electrolyte (Suplena) Supplemented with arginine, glutamine, omega-3 FA (Impact) AKI without dialysis Short bowel syndrome Multiple trauma Fluid restricted A-2 B-4 C-1 D-3

Which of these statements is true? Soluble fiber adds bulk to the stool. Bismuth subsalicylate is the preferred agent for treatment of diarrhea with EN. Gastric residuals >100 are an indication to stop EN. Erythromycin 1g IV q6h is an appropriate treatment for elevated gastric residuals. B

Other lectures

Nutrition in Liver Failure cirrhosis Risk of hyperglycemia Elevated aromatics, decreased BCAA Acute hepatitis Risk of hypoglycemia Both aromatics and BCAA are elevated but aromatics more elevated than BCAA -pts are at risk of hypoMg, hypophos, hypoCa (if hypoMg) -at risk of Wernicke’s: give thiamine before any carbs are given in TPN or EN! -NO copper or manganese!

Nutrition in Obesity Obese patients will burn their own fat if you give them a hypocaloric diet Give more protein to obese patients Need more protein to get the same anabolic effect (~2.5 g/kg/day) Do not give a hypocaloric, high protein diet to obese patients with renal failure or hepatic disease

Which of these is not true about geriatric patients? Have a decreased total body water More concentrated urine Impaired thirst Susceptible to hyperkalemia B

PK is a patient with AKI who will be starting dialysis in two days and will be receiving intradialytic protein. How much protein should PK receive per day for now? 0.8 g/kg/day 1.2 g/kg/day 2 g/kg/day 2.5 g/kg/day B

PK is now on CRRT. How much protein does he need now per day? 0.8 g/kg/day 1.2 g/kg/day 2 g/kg/day 2.5 g/kg/day D

Which trace element needs to be held in patients with renal failure? Copper Manganese Selenium chromium C (MTE-4)

Drug-Nutrient Interactions Isoniazid-vitamin B6 deficiency (give pyridoxine!) MetforminVit B12 malabsorption What drugs do you hold EN for? Phenytoin capsules: 2 hours before and after Warfarin: 1 hour before and after

D 30%, AA 4% @ 85 mL/hr How many grams of each macronutrient is the patient getting? How many g/kg of protein? How many kcals?

D20%, AA5%, IL2% @ 75 mL/hr 70 kg How many g/kg/day of protein? How many kcal/day from dextrose? How many kcal/day from protein? What percent of total daily calories are from dextrose? 1.2 g/kg/day of protein 360 kcal/day from fat 1224 kcal/day from dextrose 360 kcal/day from protein 62% of kcal from dextrose